Journal of Affective Disorders 253 (2019) 292–302

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Influencing factors for prenatal Stress, anxiety and depression in early T

pregnancy among women in Chongqing, China
⁎
Tang Xian, Lu Zhuo, Hu Dihui, Zhong Xiaoni
School of Public Health and Management, Chongqing Medical University, 1# yixue Rd., Chongqing 400016, China

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Prenatal mental disorders are associated with maternal and fetal adverse outcomes, while few
Prenatal stress studies have been performed in mainland China. This study aimed to investigate the prevalence and influencing
Prenatal anxiety factors of maternal stress, anxiety and depression in early pregnancy and provide scientific basis for reducing
Prenatal depression prenatal mental disorders.
Prevalence
Methods: Data were obtained from 1220 women with < 15 weeks gestation in a cohort study conducted in
Influencing factors
Chongqing, China. Prenatal stress, anxiety and depression were assessed using the pregnancy pressure scale, the
Mainland China
Hamilton anxiety scale, and the self-rating depression scale, respectively.
Results: The prevalence of prenatal stress, anxiety and depression in early pregnancy was 91.86%, 15.04% and
5.19%, respectively. Logistic regression analysis revealed that the risk factors for prenatal stress include
housewife/unemployment, presence of anxiety and low- and moderate-level social support, besides, the pro-
tective factors were exercise, active smoking and no suggestion from parents. Housewife/unemployment, pri-
miparity, presence of stress and depression and low-level social support were found to be associated with the
development of anxiety symptoms, whereas exercise had a protective effect on it. Group-oriented personality,
presence of anxiety, no suggestion from husband, low- and moderate-level family care, and low-level social
support were risk factors for prenatal depression.
Limitations: All participants were recruited from one region of China, and none of them have a history of ce-
sarean section.
Conclusion: Early screening and intervention may have great significance for reducing mental disorders of
pregnant women, and the family and society support should be brought into the intervention as well.

1. Introduction
Pregnancy leads women into a new stage in their lives, which grants
them a new name of “mother”, and makes them experience biological
and psychological changes as well as status transitions in family and
sociality. Almost all women suffer from mental disorders of different
types and degrees for some reason during this period, among which
stress, anxiety and depression are the most common and often co-
morbid (Furber et al., 2009;Pampaka et al., 2018a).
Previous studies have largely focused on postnatal mental disorders,
particularly postnatal depression (Howard et al., 2014), and few studies
have been conducted on prenatal mental problems. A growing number
of literatures reported that the prevalence of mental disorders was
higher in the prenatal period than in the postnatal period (Dennis et al.,
2017; Sidebottom et al., 2014), and that prenatal mental disorders
(stress, anxiety and depression, etc.) were not only associated with
maternal and fetal adverse outcomes, including fetal abnormalities, low
birth weight, preterm birth, stillbirth, and obstetric complications
(Alder et al., 2007; Bansil et al., 2010; Grote et al., 2010; Staneva et al.,
2015), but also had enduring effects directly or indirectly on children's
growth and development. Offspring of pregnant women with one or
more of these mental disorders during pregnancy had a higher risk of
behavioral/emotional problems, attention deficit hyperactivity disorder
(ADHD), and autism in childhood (O'Connor et al., 2002; Van den
Bergh and Marcoen, 2004; Walder et al., 2014), depression, impulsivity
and cognitive disorders in adolescence (Bergh et al., 2005; Pawlby
et al., 2009), and schizophrenia in adulthood (Mäki et al., 2009). In
addition, pregnant women may be more likely to have postnatal de-
pression if they experienced mental disorders such as anxiety, depres-
sion, perceived stress, and post-traumatic stress disorder (PTSD) in the
prenatal period (Milgrom et al., 2008; Pampaka et al., 2018b). There-
fore, prenatal mental disorders have won increasing attention from

⁎
Corresponding author.
E-mail address: zhongxiaoni@cqmu.edu.cn (X. Zhong).

https://doi.org/10.1016/j.jad.2019.05.003
Received 23 January 2019; Received in revised form 29 March 2019; Accepted 1 May 2019
Available online 02 May 2019
0165-0327/ © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
X. Tang, et al.
researchers, and have recently become the research priority of public
health in various countries.
The prevalence of prenatal anxiety and depression in each trimester
of pregnancy was estimated to be 18.2%−24.6% and 7.4%−12.8%,
respectively, in international studies (Bennett et al., 2004; Dennis et al.,
2017). Risk factors including lack of social support (Bayrampour et al.,
2015), history of mental illness (Bayrampour et al., 2015; Giardinelli
et al., 2012), history of domestic violence and abuse (Akçalı Aslan et al.,
2014; Fisher et al., 2013), unplanned/unexpected pregnancy
(Bunevicius et al., 2009; Waqas et al., 2015), and miscarriage
(Fisher et al., 2013) were considered significantly correlated to prenatal
anxiety and depression, while evidence for sociodemographic (age,
income level) and obstetric (parity) factors have not been identified
(Biaggi et al., 2016). The prevalence of prenatal stress was reported to
be 12%−84% in several studies, and the associated factors include lack
of social support, domestic violence, drug abuse and panic disorder
(Kingston et al., 2012; Shishehgar et al., 2016; Woods et al., 2010).
In recent years, prenatal stress, anxiety, and depression are in-
creasingly common among Chinese women, like their counterparts in
other countries. However, there may be great differences among re-
gions in China. Previous studies on prenatal anxiety or depression
mainly focused on the associations with pregnancy outcomes, the ef-
fectiveness of interventions and the development in specific subgroups
(such as pregnant women with gestational diabetes mellitus and
threatened abortion, etc.), and less research has been conducted on the
influencing factors. The prevalence of prenatal anxiety was about
1.8%−42.1% (Hou et al., 2018; Tao, 2016; Zhang, 2017; Zheng, 2011)
and depression 3.6%−40.2% (Li et al., 2012; Tao, 2016; Zhang, 2017;
Zheng, 2011) in Chinese women. Reported risk factors for prenatal
anxiety and depression include young age, low levels of education,
disharmony in the family relationship, low life satisfaction, and lack of
social support (Kang et al., 2016; Lau et al., 2014; QIAO et al., 2009;
Zhao et al., 2014). In terms of prenatal stress, studies in China mainly
focused on the stress levels, stressors, and associations with adverse
outcomes, and little research has been done on the prevalence. These
studies have suggested that Chinese women have mild to moderate
prenatal stress, which was found to be related to low monthly per capita
household income, obstetric complications, miscarriage experience,
frequent cooking, and bad sleep quality, and that the main stressors
include worries about fetal abnormalities, safety of delivery, abnormal
conditions during childbirth/cesarean section and labor pain (Hou
et al., 2018; Song et al., 2013; Zhang, 2017).
Moreover, the past studies on Chinese women have paid much less
attention to early pregnancy than to other periods. To our knowledge,
few researches on the prevalence or influencing factors of mental dis-
orders in early pregnancy have been carried out across the globe, apart
from two studies providing the prevalence of anxiety and depression in
the first trimester (Li et al., 2012; Yu et al., 2017). Although some
studies reported the findings in Hong Kong, the data may not be ap-
plicable to the mainland due to the obvious economic and cultural gaps
(Chan et al., 2013; Lee et al., 2007). Besides, statistical data on prenatal
mental disorders in mainland China are scarce. At present, we have
only found two studies reporting the prevalence or influencing factors
of stress in early pregnancy (Lin et al., 2019; Zhang et al., 2017) and
several studies reporting the results of anxiety or depression. However,
there might be some limitations in these studies, such as the use of
unrecognized psychological assessment methods, small sample size and
biased sample sources (Ding et al., 2015; Meng and Liu 2011; Sun,
2012; Zhang et al., 2011). The prevalence of early pregnancy anxiety
and depression that are reported in these studies is more representative,
however, none of them investigated the associated factors (Tao, 2016;
Zhang, 2017; Zheng, 2011). Li et al. (2019) discussed the influencing
factors of anxiety in early pregnancy but did not report the prevalence
rate. Only Wang, J. (2014) and Wang et al. (2015) conducted a rela-
tively comprehensive study on the prevalence and influencing factors of
early pregnancy depression.
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Journal of Affective Disorders 253 (2019) 292–302
As far as we know, studies on the prevalence and influencing factors
of stress, anxiety and depression in early pregnancy have been con-
ducted extensively only in several provinces in mainland China (Hunan
province and Anhui province, etc.), and less or no research on some of
these mental problems have been carried out in most regions, such as
those five provinces in southwest China where Chongqing is located. At
present, we found that there was no research on prenatal stress, anxiety
and depression in early pregnancy among women in Chongqing.
Furthermore, many researchers have found that stress, anxiety and
depressive symptoms were co-existed, but only few studies in China
have discussed them all together. Therefore, based on a prospective
pregnancy cohort study in Chongqing, we explored the occurrence of
prenatal stress, anxiety and depression in early pregnancy among
mainland Chinese women, and reported the prevalence and influencing
factors of early pregnancy stress, anxiety and depression in Chongqing
for the first time. This study is an expansion and enrichment to the
maternal mental disorder researches in early pregnancy in mainland
China, which can help us better understand the negative emotions of
women during pregnancy in Chongqing, the southwest regions and
mainland in China. And it can also provide a basis for formulating
maternal health care policies and guidelines to improve the welfare of
pregnant women.
2. Methods
2.1. Study procedures
The data of our study were collected from “Study on the Public
Opinion Propagation Model for Generative Mechanism and Regularity
of Cesarean Delivery Behavior”, which was a prospective cohort study
initiated by the National Natural Science Foundation of China. The
study has been approved by Ethics Committee of Chongqing Medical
University and conducted in Chongqing, a provincial city in south-
western China. Participants were recruited from the department of
gynecology and obstetrics at four hospitals in four regions with dif-
ferent economic conditions (developed regions: Yubei district and
Jiangjin district, less-developed regions: Dianjiang district and Yunyang
district). All participants attending the initial examination of pregnancy
(January 2018–September 2018) in these hospitals were screened, and
a total of 1220 women who met the inclusion and exclusion criteria and
signed the informed consent were included in this study.
Inclusion criteria: women with singleton pregnancy, gestational
age <15 weeks, and willingness to participate in the cohort study.
Exclusion Criteria: women with histories of cesarean section, or with
health problems, such as mental illness.
Participants recruitment: (a) Investigators who were trained and
experienced nurses in these hospitals selected qualified participants
according to inclusion and exclusion criteria; (b) Investigators carried
out face-to-face interviews with participants, and informed them of the
relevant content of the study; (c) Participants who were willing to take
part in the study signed the written informed consent.
2.2. Study content and measurements
A structured questionnaire containing four aspects was used in this
study. Part of the data were collected from the maternal health man-
agement manual in which all medical records from the initial ex-
amination of pregnancy to child's schooling were kept.
2.2.1. Assessment of maternal Stress, anxiety and depression in early
pregnancy
2.2.1.1. Prenatal stress. Prenatal stress was measured using the
pregnancy pressure scale (PPS) compiled by Chen Zhanghui et al.
(Zhang, 2005). The scale has been widely applied to related studies in
Chinese pregnant women and showed favorable reliability and validity
(Pan et al., 2004). PPS consists of thirty items and reflects four aspects:
X. Tang, et al.
(a) identity of parents’ roles, (b) health and safety of the mother and
child, (c) changes in body shape and physical activities and (d) other
stressors. Responses are rated on a 4-point Likert scale ranging from 0
(no stress) to 3 (severe stress). The average score of all items is
calculated to assess the level of prenatal stress, and higher scores
indicate the higher level, with 0 for no stress, 0.01–1.00 for mild stress,
1.01–2.00 for moderate stress and 2.01–3.00 for severe stress. This
study only explored whether pregnant women have stress symptoms, so
the average score of >0 was considered to be stressful.
2.2.1.2. Prenatal anxiety. Prenatal anxiety was assessed by the
Hamilton anxiety scale (HAMA), which has been widely used in
Chinese pregnant women (Hou and Wang, 2006; Liu and Yang, 2012;
Zhang, 2005). HAMA reflects two aspects through fourteen items. One
is somatic anxiety and the other is psychological anxiety. The presence
of anxiety symptoms is assessed by a 5-point Likert scale ranging from 0
(no symptom) to 4 (severe anxiety), and higher total scores indicate
greater anxiety. In this study, we only explored whether pregnant
women have anxiety symptoms, so a total score of > 14 was considered
to be anxious.
2.2.1.3. Prenatal depression. Considering the applicability, reliability
and validity of prenatal studies in China and educational level of
participants, the self-rating depression scale (SDS) (Zung, 1965),
commonly used in the psychological assessment of pregnant women
in China, was used to measure prenatal depression. SDS consists of
twenty items. Considering the large number of research items and the
feasibility in pregnant population in the cohort study, only ten items
were used after the items overlapping with HAMA were eliminated. SDS
is a 4-point Likert scale ranging from 1 (no/a little of the time) to 4
(most of the time/all the time) to capture symptoms of prenatal
depression. The depression level is assessed by the depression index
(=actual total score / the highest possible score for all items). Higher
scores indicate more severe depression. In this study, we only explored
whether pregnant women have depressive symptoms, so the index of
≥ 0.5 was considered to be depressive (Duan and Sheng, 2012).
2.2.2. Personal influencing factors
Personal influencing factors include sociodemographic character-
istics, personality traits, knowledge-attitude-practice, obstetric char-
acteristics and exposure to suspected adverse factors.
The sociodemographic characteristics include age, place of re-
sidence, education level, working status during pregnancy and monthly
per capita household income.
Knowledge-attitude-practice includes exercise during pregnancy,
source of pregnancy-related knowledge (television, internet, books and
magazines, hospital promotional materials, hospital training, medical
personnel, maternity schools, others’ maternal experiences, other
pregnant women in the same hospital), expected delivery mode, and
pregnancy-related knowledge judgement.
Obstetric characteristics contain BMI (at the initial examination of
pregnancy), gestational age, parity, number of abortions, fever in the
first trimester, vaginal bleeding, previous medical history, and family
history (data were obtained from the maternal health management
manual).
Suspected adverse factors contain the use of at-risk drugs, domestic
pets, drinking, and smoking (data were obtained from the maternal
health management manual).
The mental health of a pregnant woman is associated with her
personality traits. The self-sufficient personality was measured by the
ten items corresponding to factor Q2 (self-sufficiency) in the 16
Personality Factor Questionnaire (16PF) revised by Zhu and Dai (1988).
In accordance with the scoring standard, two points are recorded for the
same answer, zero for the opposite answer, and one for the moderate
answer. The total raw score was calculated and then converted to a
standard score (0–10) according to the norm for Chinese adult women.
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Journal of Affective Disorders 253 (2019) 292–302
Higher scores indicate greater independence, with 3 points and below
for group-oriented personality, 4–7 for the intermediate state and 8
points and above for self-sufficient personality. 16PF has been widely
used in the study of personality traits in various groups in China, and
shows good reliability and validity.
2.2.3. Family influencing factors
Family influencing factors include family care and family members’
suggestion on delivery mode (husband, parents and parents-in-law).
The family adaptation partnership growth affection and resolve
index (APGAR) has been widely used in Chinese pregnant women and
proven to be valid and reliable (Smilkstein et al., 1982; Sun et al.,
2018). APGAR consists of five items and reflects five aspects: adapta-
tion, partnership, growth, affection and resolve. Responses are rated on
a 3-point Likert scale ranging from 0 (rare) to 2 (often). The level of
family care obtained by pregnant women is assessed with the total score
of all items. Higher scores indicate better family care with 0–3 for a low
level, 4–6 for a moderate level, and 7–10 for a high level.
2.2.4. Social influencing factors
Social influencing factors contain social support, medical staff ser-
vice and friends' suggestion on delivery mode.
The social support level was measured using the social support
rating scale (SSRS) compiled by Xiao, (1994), which has been widely
used in Chinese populations including pregnant women and shows good
reliability and validity (Sun et al., 2018; Xiao, 1994; Zheng et al.,
2018). SSRS consists of ten items including three aspects: (a) objective
support, (b) subjective support and (c) utilization of social support. The
level of social support obtained by pregnant women is assessed with the
total score. Higher scores indicate more social support with less than 35
for a low level, 35–45 for a moderate level, and higher than 45 for a
high level (Sun et al., 2018).
2.3. Statistical analysis
Statistical analyses were performed with SAS version 9.4. According
to the research purpose, some of the continuous variables (age, preg-
nancy-related knowledge judgment score, personality traits score, fa-
mily care score, social support score, prenatal stress score, prenatal
anxiety score and prenatal depression score) in this study were con-
verted into categorical variables. The χ2 test and Fisher's exact test were
used to examine associations between prenatal stress, anxiety and de-
pression and categorical variables. The variables with p ≤ 0.1 in the
univariate analysis were brought into the logistic regression analysis
with the stepwise procedure (sle = 0.05, sls = 0.05). In addition,
considering stress, anxiety and depression were co-existed, when one of
the three variables were set as the dependent variable, the other two
were brought into the multivariate analysis as control variables re-
gardless of whether the results of univariate analysis are significant.
The actual number of participants who were included in the statistical
analysis of prenatal stress, anxiety, and depression were 1204, 1210,
and 1215, respectively, since a small number of women failed to
complete the study. Missing rates of variables were all below 1.5%, and
observations with missing values were excluded from the analyses
(Table 1).
3. Results
3.1. Participants’ characteristics
All participants aged 16–44 years (mean=25.8) with an average
gestational age of 10.7 weeks. Sixty point nine percent of women lived
in urban areas and 39.1% in rural areas. Almost half of women (53.8%)
still work after pregnancy, 42.2% had a college degree or above, 30.6%
had a high school/secondary school degree, and 27.1% had a junior
high school degree or below. Forty one point six percent of the
X. Tang, et al. Journal of Affective Disorders 253 (2019) 292–302

Table 1
Sample characteristics of pregnant women and univariate analysis.
Characteristics Total No Stress Stress p Value No Anxiety Anxiety p Value No Depression Depression p Value
n (%) n (%) n (%) n (%) n (%) n (%) n (%)

N 1220(100.00) 98(8.14) 1106(91.86) 1028(84.96) 182(15.04) 1152(94.81) 63(5.19)

Personal factors
Age(years) 0.4730 0.0231 0.3766
≤ 19 36(2.95) 1(2.78) 35(97.22) 29(80.56) 7(19.44) 34(94.44) 2(5.56)
20–24 474(38.85) 33(7.04) 436(92.96) 380(81.02) 89(18.98) 444(93.67) 30(6.33)
25–29 495(40.57) 43(8.79) 446(91.21) 429(87.20) 63(12.80) 470(95.33) 23(4.67)
30–34 161(13.20) 16(10.13) 142(89.87) 141(88.13) 19(11.88) 152(95.00) 8(5.00)
≥ 35 51(4.18) 5(10.20) 44(89.80) 46(92.00) 4(8.00) 49(100.00) 0(0.00)
Missing Data 3(0.25) 0(0.00) 3(100.00) 3(100.00) 0(0.00) 3(100.00) 0(0.00)
Working Status 0.0051 0.0010 0.3101
Employment 656(53.77) 66(10.19) 582(89.81) 571(88.12) 77(11.88) 624(95.41) 30(4.59)
Housewife/Unemployment 564(46.23) 32(5.76) 524(94.24) 457(81.32) 105(18.68) 528(94.12) 33(5.88)
Exercise during Pregnancy 0.0515 <0.0001 0.0083
Yes 564(46.23) 55(9.79) 507(90.21) 504(90.00) 56(10.00) 543(96.62) 19(3.38)
No 655(53.69) 43(6.71) 598(93.29) 524(80.74) 125(19.26) 608(93.25) 44(6.75)
Missing Data 1(0.08) 0(0.00) 1(100.00) 0(0.00) 1(100.00) 1(100.00) 0(0.00)
Source of Pregnancy-Related 0.6307 0.0103 0.2832
Knowledge: Hospital Promotional
Materials
Yes 322(26.39) 28(8.78) 291(91.22) 287(89.41) 34(10.59) 308(95.95) 13(4.05)
No 897(73.52) 70(7.92) 814(92.08) 741(83.45) 147(16.55) 843(94.40) 50(5.60)
Missing Data 1(0.08) 0(0.00) 1(100.00) 0(0.00) 1(100.00) 1(100.00) 0(0.00)
Source of Pregnancy-Related 0.6209 0.8337 0.0321
Knowledge: Medical Personnel
Yes 196(16.07) 14(7.25) 179(92.75) 164(84.54) 30(15.46) 190(97.94) 4(2.06)
No 1023(83.85) 84(8.32) 926(91.68) 864(85.12) 151(14.88) 961(94.22) 59(5.78)
Missing Data 1(0.08) 0(0.00) 1(100.00) 0(0.00) 1(100.00) 1(100.00) 0(0.00)
Source of Pregnancy-Related 0.8305 0.1920 0.0429
Knowledge: Others' Maternal
Experiences
Yes 497(40.74) 39(7.94) 452(92.06) 428(86.64) 66(13.36) 477(96.36) 18(3.64)
No 722(59.18) 59(8.29) 653(91.71) 600(83.92) 115(16.08) 674(93.74) 45(6.26)
Missing Data 1(0.08) 0(0.00) 1(100.00) 0(0.00) 1(100.00) 1(100.00) 0(0.00)
Source of Pregnancy-Related 0.6953 0.2613 0.0157
Knowledge: Other Pregnant Women
in the Same Hospital
Yes 99(8.11) 9(9.18) 89(90.82) 88(88.89) 11(11.11) 98(100.00) 0(0.00)
No 1120(91.80) 89(8.05) 1016(91.95) 940(84.68) 170(15.32) 1053(94.35) 63(5.65)
Missing Data 1(0.08) 0(0.00) 1(100.00) 0(0.00) 1(100.00) 1(100.00) 0(0.00)
Pregnancy-Related Knowledge 0.6866 0.0437 0.0090
Judgment
Low 252(20.66) 23(9.43) 221(90.57) 202(80.80) 48(19.20) 230(91.27) 22(8.73)
Moderate 749(61.39) 57(7.68) 685(92.32) 631(85.16) 110(14.84) 710(95.30) 35(4.70)
High 219(17.95) 18(8.26) 200(91.74) 195(89.04) 24(10.96) 212(97.25) 6(2.75)
Expected Delivery Mode 0.5155 0.0994 0.0118
Not Considered Yet 533(43.69) 39(7.43) 486(92.57) 451(85.26) 78(14.74) 498(93.79) 33(6.21)
Natural Delivery 626(51.31) 52(8.41) 566(91.59) 531(85.65) 89(14.35) 600(96.31) 23(3.69)
Cesarean Section 61(5.00) 7(11.48) 54(88.52) 46(75.41) 15(24.59) 54(88.52) 7(11.48)
Parity 0.5473 0.0028 0.0846
0 (primiparity) 827(67.79) 64(7.81) 755(92.19) 681(82.85) 141(17.15) 776(94.06) 49(5.94)
≥1 393(32.21) 34(8.83) 351(91.17) 347(89.43) 41(10.57) 376(96.41) 14(3.59)
Number of Abortions 0.4622 0.0867 0.3544
0 724(59.34) 54(7.53) 663(92.47) 613(85.38) 105(14.62) 685(94.74) 38(5.26)
1 286(23.44) 28(9.89) 255(90.11) 248(87.32) 36(12.68) 274(96.14) 11(3.86)
≥2 210(17.21) 16(7.84) 188(92.16) 167(80.29) 41(19.71) 193(93.24) 14(6.76)
At-Risk Drug Use 0.8922 0.0373 0.0190*
Yes 67(5.49) 5(7.69) 60(92.31) 51(76.12) 16(23.88) 59(88.06) 8(11.94)
No 1153(94.51) 93(8.17) 1046(91.83) 977(85.48) 166(14.52) 1093(95.21) 55(4.79)
Smoking 0.0575* 0.0030 0.1248*
Active 18(1.48) 4(22.22) 14(77.78) 11(61.11) 7(38.89) 16(88.89) 2(11.11)
Passive 43(3.52) 5(11.63) 38(88.37) 41(95.35) 2(4.65) 43(100.00) 0(0.00)
No 1159(95.00) 89(7.79) 1054(92.21) 976(84.94) 173(15.06) 1093(94.71) 61(5.29)
Previous Medical History 0.6556 0.0156 0.7850
Yes 109(8.93) 10(9.26) 98(90.74) 84(77.06) 25(22.94) 103(95.37) 5(4.63)
No 1111(91.07) 88(8.03) 1008(91.97) 944(85.74) 157(14.26) 1049(94.76) 58(5.24)
Personality 0.2284* 0.0737 0.0004*
Group-Oriented 37(3.03) 1(2.78) 35(97.22) 28(77.78) 8(22.22) 29(78.38) 8(21.62)
Intermediate State 1148(94.10) 92(8.12) 1041(91.88) 975(85.53) 165(14.47) 1091(95.45) 52(4.55)
Self-Sufficient 35(2.87) 5(14.29) 30(85.71) 25(73.53) 9(26.47) 32(91.43) 3(8.57)
Stress 0.0016 0.4727*
Yes 1106(90.66) 925(84.09) 175(15.91) 1046(94.75) 58(5.25)
No 98(8.03) 94(95.92) 4(4.08) 95(96.94) 3(3.06)
Missing Data 16(1.31) 9(75.00) 3(25.00) 11(84.62) 2(15.38)
(continued on next page)

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X. Tang, et al. Journal of Affective Disorders 253 (2019) 292–302

Table 1 (continued)

Characteristics Total No Stress Stress p Value No Anxiety Anxiety p Value No Depression Depression p Value
n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Anxiety 0.0016 <0.0001

Yes 182(14.92) 4(2.23) 175(97.77) 143(79.44) 37(20.56)
No 1028(84.26) 94(9.22) 925(90.78) 1001(97.47) 26(2.53)
Missing Data 10(0.82) 0(0.00) 6(100.00) 8(100.00) 0(100.00)
Depression
Yes 63(5.16) 3(4.92) 58(95.08) 0.4727* 26(41.27) 37(58.73) <0.0001
No 1152(94.43) 95(8.33) 1046(91.67) 1001(87.50) 143(12.50)
Missing Data 5(0.41) 0(0.00) 2(100.00) 1(33.33) 2(66.67)
Family Factors
Family Care 0.0525 <0.0001 <0.0001
Low 75(6.15) 2(2.70) 72(97.30) 52(69.33) 23(30.67) 60(80.00) 15(20.00)
Moderate 306(25.08) 19(6.31) 282(93.69) 237(78.48) 65(21.52) 275(90.46) 29(9.54)
High 830(68.03) 77(9.37) 745(90.63) 734(88.75) 93(11.25) 809(97.71) 19(2.29)
Missing Data 9(0.74) 0(0.00) 7(100.00) 5(83.33) 1(16.67) 8(100.00) 0(0.00)
Husband's Suggestion on Delivery Mode 0.0293 0.6621 0.0215
Natural Delivery/Cesarean Section/ 906(74.26) 64(7.13) 833(92.87) 767(85.22) 133(14.78) 863(95.68) 39(4.32)
No Specific Suggestion
No Suggestion 314(25.74) 34(11.07) 273(88.93) 261(84.19) 49(15.81) 289(92.33) 24(7.67)
Parents' Suggestion on Delivery Mode 0.0004 0.9080 0.8414
Natural Delivery/Cesarean Section/ 956(78.36) 63(6.67) 882(93.33) 806(85.02) 142(14.98) 902(94.75) 50(5.25)
No Specific Suggestion
No Suggestion 264(21.64) 35(13.51) 224(86.49) 222(84.73) 40(15.27) 250(95.06) 13(4.94)
Parents-in-law's Suggestion on Delivery 0.0025 0.1774 0.2243
Mode
Natural Delivery/Cesarean Section/ 912(74.75) 61(6.76) 841(93.24) 777(85.76) 129(14.24) 865(95.26) 43(4.74)
No Specific Suggestion
No Suggestion 308(25.25) 37(12.25) 265(97.75) 251(82.57) 53(17.43) 287(93.49) 20(6.51)
Social Factors
Medical Staff Service 0.0659 0.0181 0.0793
Great 890(72.95) 81(9.24) 796(90.76) 764(86.62) 118(13.38) 843(95.15) 43(4.85)
Good 255(20.90) 12(4.76) 240(95.24) 206(81.42) 47(18.58) 242(95.28) 12(4.72)
General and Below 74(6.07) 5(6.76) 69(93.24) 57(77.03) 17(22.97) 66(89.19) 8(10.81)
Missing Data 1(0.08) 0(0.00) 1(100.00) 1(100.00) 0(0.00) 1(100.00) 0(0.00)
Friends' Suggestion on Delivery Mode 0.0005 0.9441 0.4168
Natural Delivery/Cesarean Section/ 961(78.77) 64(6.72) 888(93.28) 811(84.92) 144(15.08) 909(95.08) 47(4.92)
No Specific Suggestion
No Suggestion 259(21.23) 34(13.49) 218(86.51) 217(85.10) 38(14.90) 243(93.82) 16(6.18)
Social Support <0.0001 <0.0001 <0.0001
Low 261(21.39) 10(3.88) 248(96.12) 178(68.73) 81(31.27) 228(88.03) 31(11.97)
Moderate 763(62.54) 57(7.55) 698(92.45) 669(88.14) 90(11.86) 732(96.06) 30(3.94)
High 179(14.67) 29(16.38) 148(83.62) 167(93.82) 11(6.18) 177(98.88) 2(1.12)
Missing Data 17(1.39) 2(14.29) 12(85.71) 14(100.00) 0(0.00) 15(100.00) 0(0.00)

⁎
Fisher's exact probability test
Bold values indicate statistical significance at P < 0.05.
Univariate analysis was performed on all variables, and for readability only those variables which had been put into the multivariate regression analysis are shown
(P ≤ 0.01).

participants’ monthly per capita household income was between
3001–5000 yuan, 34.9% was greater than 5000 yuan ($728), and
23.1% was equal or less than 3000 yuan ($437) (Table 1). (The data of
gestational age, education level, place of residence, and monthly per
capita household income were shown in Appendix (Table 5).)
3.2. The prevalence and influencing factors of maternal stress in early
pregnancy
Ninety one point eight six percent (1106 of 1204) of pregnant
women experienced pregnancy stress in early pregnancy (Table 1).
In the univariate analysis, significant differences in the prevalence
of prenatal stress were observed among the groups in the working
status, prenatal anxiety, family members’ (husband, parents and par-
ents-in-law) and friends’ suggestion on delivery mode and social sup-
port (P < 0.05) (Table 1).
In the multivariate model (Table 2), housewives and women who
were not working were 1.82 times more likely to experience prenatal
stress than women who continued to work after pregnancy (OR 1.816,
95%CI 1.136–2.905). The presence of anxiety symptoms during preg-
nancy also increased the risk of prenatal stress (OR 3.463, 95%CI
1.204–9.961). Although the number of women smoking during preg-
nancy was extremely low, smoking actively reduced the odds of pre-
natal stress (OR 0.145, 95%CI 0.041–0.509), as did keeping on exercise
during pregnancy (OR 0.631, 95%CI 0.405–0.983). In terms of family
influencing factors, maternal prenatal stress was related to parents’
suggestion on delivery mode and it would be significantly decreased if
their parents did not provide any suggestion (OR 0.446, 95%CI
0.282–0.704). In regard to social influencing factors, women with low
or moderate levels of social support were more likely to experience
prenatal stress than those with high-level social support (OR 3.188,
95%CI 1.460–6.962; OR 1.962, 95%CI 1.191–3.229, respectively).
3.3. The prevalence and influencing factors of maternal anxiety in early
pregnancy
Fifteen point zero four percent (182 of 1210) of pregnant women
experienced anxiety in early pregnancy (Table 1).
In the univariate analysis, significant differences in the prevalence
of prenatal anxiety were observed between groups with different
characteristics, including age, working status, exercise during preg-
nancy, source of pregnancy-related knowledge (hospital promotional

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X. Tang, et al. Journal of Affective Disorders 253 (2019) 292–302

Table 2 Table 4
Model 1: multivariate logistic regression of prenatal stress (N = 1204). Model 3: multivariate logistic regression of prenatal depression (N = 1215).
Variables β Wald p Value OR (95%CI) Variables β Wald p Value OR (95%CI)

Working Status Personality

Employment reference Group-Oriented 0.1749 12.6369 0.0004 6.447(2.307–18.015)
Housewife/ 0.1641 6.2033 0.0128 1.816(1.136–2.905) Intermediate State reference
Unemployment Self-Sufficient 0.0721 1.3077 0.2528 2.181(0.573–8.298)
Exercise during Pregnancy Anxiety
Yes −0.1266 4.1362 0.0420 0.631(0.405–0.983) Yes 0.4299 55.4339 <0.0001 8.912(5.011–15.852)
No reference No reference
Smoking Family Care
Active −0.1310 9.0694 0.0026 0.145(0.041–0.509) Low 0.2636 23.8534 <0.0001 7.231(3.269–15.997)
Passive −0.0271 0.2758 0.5995 0.768(0.286–2.060) Moderate 0.2948 14.2163 0.0002 3.442(1.810–6.544)
No reference High reference
Anxiety Husband's Suggestion on Delivery Mode
Yes 0.2446 5.3115 0.0212 3.463(1.204–9.961) Natural Delivery/ reference
No reference Cesarean Section/
Parents' Suggestion on Delivery Mode No Specific
Natural Delivery/ reference Suggestion
Cesarean Section/No No Suggestion 0.1991 7.3660 0.0066 2.298(1.260–4.190)
Specific Suggestion
No Suggestion −0.1822 12.0060 0.0005 0.446(0.282–0.704) β, standardized regression coefficients. OR, adjusted odds ratio. 95% CI, 95%
Social Support confidence interval.
Low 0.2633 8.4655 0.0036 3.188(1.460–6.962) Bold values indicate statistical significance at P < 0.05.
Moderate 0.1790 7.0151 0.0081 1.962(1.191–3.229)
High reference
anxiety. Women with low-level social support were 5.1 times more
β, standardized regression coefficients. OR, adjusted odds ratio. 95% CI, 95% likely to develop anxiety than did those with high-level social support
confidence interval. (OR 5.097, 95%CI 2.410–10.779). No significant differences were
Bold values indicate statistical significance at P < 0.05. found in the prevalence of anxiety symptoms between women with
moderate-level social support and those with high-level social support.
materials), pregnancy-related knowledge judgement, parity, at-risk
drug use, smoking, previous medical history, prenatal stress, prenatal 3.4. The prevalence and influencing factors of maternal depression in early
depression, family care, medical staff service, and social support pregnancy
(P < 0.05) (Table 1).
In the multivariate model (Table 3), primiparas had a higher risk of Five point one nine percent (63 of 1215) of pregnant women ex-
anxiety than multiparas (OR 1.516, 95%CI 1.010–2.276). Housewives perienced depression in early pregnancy (Table 1).
and women who were not working after pregnancy were more likely to In the univariate analysis, significant differences in the prevalence
experience anxiety than women who continued to work (OR 1.544, of prenatal depression were found among the groups in personality
95%CI 1.080–2.206). Similar to prenatal stress, keeping on exercise traits, exercise during pregnancy, source of pregnancy-related knowl-
reduced the odds of prenatal anxiety as well (OR 0.548, 95%CI edge (medical personnel, others’ maternal experiences, other pregnant
0.379–0.794). However, the presence of stress or depression increased women in the same hospital), pregnancy-related knowledge judgment,
the risk of prenatal anxiety (OR 3.121, 95%CI 1.063–9.162; OR 7.812, expected delivery mode, at-risk drug use, prenatal anxiety, family care,
95%CI 4.382–13.925 respectively). Lack of social support also triggered husband's suggestion on delivery mode and social support (P < 0.05)
(Table 1).
Table 3 In the multivariate model (Table 4), the group-oriented personality
Model 2: multivariate logistic regression of prenatal anxiety (N = 1210). and the presence of anxiety symptoms increased women's odds of pre-
natal depression (OR 6.447, 95%CI 2.307–18.015; OR 8.912 95%CI
Variables β Wald p Value OR (95%CI)
5.011–15.852 respectively). In terms of family factors, women with
Working Status low- and moderate-level family care were 7.2 times and 3.4 times re-
Employment reference spectively more likely to have depressive symptoms than did those with
Housewife/ 0.1194 5.6865 0.0171 1.544(1.080–2.206) high-level family care (OR 7.231, 95%CI 3.269–15.997; OR 3.442,
Unemployment
95%CI 1.810–6.544 respectively). Moreover, maternal prenatal de-
Exercise during Pregnancy
Yes −0.1653 10.1174 0.0015 0.548(0.379–0.794) pression was related to husbands’ suggestion on delivery mode and it
No reference would be significantly increased if their husbands did not provide any
Parity suggestion (OR 2.298 95%CI 1.260–4.190).
0 (primiparity) 0.1069 4.0342 0.0446 1.516(1.010–2.276)
≥1 reference
Stress 4. Discussion
Yes 0.1723 4.2925 0.0383 3.121(1.063–9.162)
No reference 4.1. The prevalence of prenatal Stress, anxiety and depression
Depression
Yes 0.2520 48.5790 <0.0001 7.812(4.382–13.925)
No reference Mental disorders are common in the prenatal period but are often
Social Support overlooked by Chinese medical institutions. The prevalence of early
Low 0.3693 18.1671 <0.0001 5.097(2.410–10.779) pregnancy stress was 91.86% in our study, which was higher than that
Moderate 0.1702 3.0028 0.0831 1.897(0.919–3.915)
(78.9%) of women in Liuyang City, Hunan Province (Lin et al., 2019).
High reference
And it was similar to the result (94.48%) of a study conducted by the
β, standardized regression coefficients. OR, adjusted odds ratio. 95% CI, 95% Chinese Center for Disease Control and Prevention (China CDC) in
confidence interval. several provinces and cities (Zhang et al., 2017). It suggests that the
Bold values indicate statistical significance at P < 0.05. prevalence of early pregnancy stress among women in Chongqing may

297
X. Tang, et al.
be in the average level in China. The prevalence of prenatal stress is
rarely reported in international studies, but there were some re-
searchers who explored the trend of stress during pregnancy and found
that the prevalence of stress in early pregnancy is the highest
(Rallis et al., 2014). Compared with the results in the second and third
trimesters of pregnancy in some studies, we did report a higher pre-
valence rate of stress (Woods et al., 2010).
In terms of prenatal anxiety, we reported a prevalence of 15.04% in
early pregnancy. Some studies have also reported the prevalence of
anxiety among women in other provinces and cities in China: 2.7% in
Ma'anshan City, Anhui Province; 29.4% in Changsha City, Hunan
Province; 22.57% in Zhoushan City, Zhejiang Province (Yu et al., 2017;
Tao, 2016; Zheng, 2011), but the results vary considerably in regions
because of the diversity of regional economy, culture and policy. The
study conducted by the China CDC also reported the prevalence of early
pregnancy anxiety and depression, which included the data of five
mainland provinces and cities, making it a better representative of the
occurrence of early pregnancy mental disorders than other studies that
conducted in only one province or city (Zhang, 2017). The result of our
study is similar to that of the China CDC (16.02%), suggesting that the
prevalence of early pregnancy anxiety in Chongqing may be in the
average level in China. In addition, the result of our study is slightly
lower than that of early pregnancy anxiety (18.2%) in a global review
article that included studies from 34 countries (Dennis et al., 2017).
The prevalence of early pregnancy depression in our study was
5.19%, which was similar to that in study conducted in Anhui Province,
China (4.7%) (Tao, 2016), but far below the results of studies con-
ducted in other provinces and the result of the study conducted by the
China CDC (12.07%−36.4%) (Li et al., 2012; Yu et al., 2017; Wang,
2014; Y.Q. et Al.; Zhang, 2017; Zheng, 2011), suggesting that the
prevalence of early pregnancy depression in Chongqing may be lower
than the average level in China. Similar to the prevalence of anxiety,
the prevalence of depression in our study was slightly lower than the
result of a review article (7.4%) as well (Bennett et al., 2004). It is well
known that due to differences in cultures, customs and norms, Asians
usually adopt a more conservative attitude than Westerners toward
some sensitive issues (Roomruangwong and Epperson, 2011). For ex-
ample, when dealing with their own mental disorders, Asians would
have a tendency of somatization, which is usually manifested by pro-
posing physical disease to conceal psychological discomfort (AM, 1977;
Wen-Shing, 1975). Moreover, Chinese researchers often apply “Wes-
tern” measurement methods and criteria when conducting studies on
mental disorders, cultural differences may lead to the neglect of specific
symptoms in Asian populations (Halbreich and Karkun, 2006). These
and some other factors may contribute to a lower reporting rate of
mental disorders in Chinese women.
4.2. Influencing factors
4.2.1. Personal influencing factors
Mental factors. Among all the variables included in this study, the
presence of other mental disorders was the strongest risk factors for
prenatal stress, anxiety or depression. Consistent with previous studies,
the presence of stress is an important risk factor for anxiety in early
pregnancy (Li et al., 2019), and the presence of anxiety symptoms are
also risk factors for early pregnancy stress (Zhang, 2017). In early
pregnancy, persistent morning sickness (Chou et al., 2008) and
concerns for income and pregnancy-related issues (fetal development,
miscarriage and fetal delivery, etc.) (Zhang et al., 2017) can cause
greater stress and emotional alterations, further leading to symptoms of
prenatal anxiety (Bowen et al., 2008), which will in turn prompt the
occurrence of prenatal stress (Zhang, 2017).
Prenatal depression is more common among women with anxiety
symptoms in early pregnancy, which is consistent with the results in
some researches (Lancaster et al., 2010; Li et al., 2016; Pampaka et al.,
2018a). A study on the psychological status of women with recurrent
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Journal of Affective Disorders 253 (2019) 292–302
spontaneous abortion not only found that pregnant women with higher
scores on anxiety scales are more prone to depression symptoms, but
also pointed out that pregnant women with higher scores on depression
scales were more prone to anxiety symptoms, which was similar to the
relationship between early pregnancy anxiety and depression in this
study (Zhang, 2017). In addition, Clark and Watson (Clark and
Watson, 1991) pointed out that there is overlapping between anxiety
and depression symptoms, which may be the reason why these two
usually coexisted.
Actually, many studies have pointed out that stress, anxiety and
depression are highly correlated (Davis et al., 2011). However, different
from the results of some relevant researches, our study did not find the
correlation between stress and depression, and the reasons might be
differences among study populations, regions, study periods and the
measurement tools adopted. (Pampaka et al., 2018a; Zhang, S.B.,
2017). The results of this study suggest that various prenatal mental
disorders are often coexisted and affect each other, therefore, the
contents of screening for prenatal mental disorders should cover as
many categories of mental disorders as possible within the feasible
extent; when finding positive cases, comprehensive analysis and inter-
vention should also be carried out in combination with the results of
multiple mental disorder screenings in order to better control the oc-
currence of prenatal mental disorders.
Other personal factors. We found that the appearance of prenatal stress
and anxiety symptoms was related to working status and exercise
during pregnancy. Consistent with previous researches, exercise can
reduce stress and anxiety and make people feel calm by changing
physical mechanisms such as hormone secretion (Bahrke and Morgan,
1978; Jackson, 2013), and housewives or women who were not
working during pregnancy had a higher risk of prenatal stress and
anxiety than did those who kept working (Baum et al., 1986; Bodecs
et al., 2013). Out of work may mean greater economic pressure, more
family conflicts, lower socioeconomic status, more unhealthy behaviors
(such as drinking and smoking), loneliness due to much unaccompanied
leisure time, and the sense of attachment because of economic
dependence, and all of these were associated with mental disorder
(Bodecs et al., 2013; Raatikainen et al., 2006; Redinger et al., 2018).
Ignoring the pressure from work temporarily and continuing to work
after pregnancy may enable pregnant women to have a better mental
state.
Pregnancy is a stressful event for women. Our study showed that
women who smoked actively were less likely to develop stress symp-
toms than those who did not smoke during pregnancy, which was
consist with the results of numerous studies on smoking motivations of
women. Smoking is seen by women as a way to cope with pressure.
They believe that smoking can reduce negative emotions such as stress
and anxiety and bring happiness, and they would love to continue this
benefit, including the period of pregnancy (Fidler and West, 2009;
Floyd et al., 1993).
We also found that primiparas were at a higher risk of anxiety,
which is consistent with the results of Giakoumaki et al. (2009), and the
reason may due to their lack of experience in becoming a mother. A
primipara's preparation for the role of motherhood in all aspects in-
clude adjustment of goals, behaviors, responsibilities and self-concep-
tion, and forming the ability to raise and educate children, thereby
promote the positive development of the child and herself
(Canavarro, 2001). Primiparas had more concerns than multiparas
since they were prone to worry about many issues, including housing,
childbirth, newborn care, and relationship with their husband/partner
(Öhman et al., 2003). Moreover, primiparas usually have higher ex-
pectations of labor pain, which make them more prone to anxiety
(Engle et al., 1990). Some studies, however, revealed that no differ-
ences were found in the prevalence of anxiety between primiparas and
multiparas (Lee et al., 2007), which may be attributed to the differences
in the regions and time of study.
X. Tang, et al.
We reported that the group-oriented personality of pregnant women
was associated with prenatal depression. Women with group-oriented
personality who “like seeking for social encouragement, lack of per-
sonal judgement, and need group support, but do not necessarily have
to live in groups” were more likely to have prenatal depressive symp-
toms (Zhu, and Dai, 1988). Sociotropic/dependent personality has been
seen as a depressive quality by many psychologists, and individuals
with this personality had a higher risk of depression when exposed to
pressure (Coyne and Whiffen, 1995). This result suggests that maternal
personality traits also need our attention while conducting the
screening for mental disorders during pregnancy. Despite a small
number of women with certain personality traits, they may have higher
susceptibility to mental disorders.
4.2.2. Family and social influencing factors
We found a higher risk of depression in pregnant women who lack
of family care. For many women, pregnancy can seriously affect their
quality of life with lifestyle restrictions due to early pregnancy reactions
and reduction in physical function (Jomeen, 2004). All these drives
women to have greater needs for family care and support, without
which they are more likely to experience prenatal depression. In early
pregnancy, women are in a sensitive transitional process of recognizing
and accepting their own physical and psychological changes. During
this period, they tend to have greater emotional alterations, lose their
temper more frequently, and be more susceptible to conflicts. Family
stress, including family conflicts, was an independent predictor of de-
pression in early pregnancy (Redinger et al., 2018). Recent problems in
marriage were associated with the onset of depression (Karaçam and
Ançel, 2009). The troublesome relationship between mother-in-law and
daughter-in-law, a unique and ubiquitous issue in China, also put
pregnant women at a higher risk of prenatal depression (Lau et al.,
2011; Yu and Zhu, 2010). Besides, most Asian families believe that
pregnancy and childbirth bring joy, but at the same time there is a
greater financial burden, especially in low-income families
(Roomruangwong and Epperson, 2011). Family financial difficulties are
associated with factors such as less autonomy of pregnant women and
more family conflicts, leading to greater risk of prenatal depression
(Rahman et al., 2003).
The practical application value of the family's advice on delivery
mode in early pregnancy is very small, but it can reflect their concern
and support for pregnant women to some extent. Therefore, in addition
to the overall function of the family, we also explored the influence of
main family members (husband, parents and parents-in-law) on preg-
nant women through their suggestions on the way of deliver.
Interestingly, we found that women who did not get advice from their
husbands were more likely to experience depression than those who got
advice; women who did not get advice from their parents were less
likely to have stress symptoms than those who got advice. In terms of
partner factors, consistent with previous studies, pregnant women who
lack support from partners, have poor relationships with their husband
and are dissatisfied with the marriage are more likely to have prenatal
depression (Karaçam and Ançel, 2009; Lau et al., 2011; Redinger et al.,
2018). In terms of parental factors, due to the one-child policy, the
majority of Chinese parents have only one child, and they often show
excessive tension and care to their “little sun” during pregnancy
(Wang and Fong, 2009). In order to protect the fetuses, the cautious
parents would require their daughter to follow traditional ways of
health care during pregnancy. They set limits on the types of food,
exercise and social activities, and always supervise whether the re-
strictions are broken; however, traditional pregnancy restrictions overly
interfere with the daily routines of pregnant women and lead to pre-
natal stress (Furber et al., 2009; Lee et al., 2009). In addition, most
Chinese women who have received modern education are skeptical
about the traditional ways of pregnancy care and they believe that
traditional pregnancy restrictions are caused by limitations of poor
living and economic conditions in the past. Some Chinese women are
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Journal of Affective Disorders 253 (2019) 292–302
gradually accepting and adopting the idea of Western perinatal nursing,
but this is different from the traditional oriental health care style ad-
vocated by parents. Cultural conflicts may lead to poor relationships
between parents and daughters, which will prompt prenatal stress
(Chang et al., 2010; Cheung, 2002). This suggests that family support
can help women maintain good mental health during pregnancy, and it
is also necessary to provide different health education for different fa-
mily members.
Lack of social support was another factor closely related to the in-
creased risk of prenatal stress and anxiety in this study, which is also
consistent with previous studies (Bayrampour et al., 2015; Glazier et al.,
2004). Providing social support is a process of interaction between
subjective and objective support of people in various aspects (such as
information, tool and emotional support, etc.) from many sources in-
cluding family, friends, neighbors, colleagues and groups involved
(Biaggi et al., 2016; Xiao, 1994). Factors including lack of support and
care from friends in the community, partner, and family members other
than her husband (Engle et al., 1990; Faisal-Cury et al., 2009; Rini
et al., 2006; Senturk et al., 2011) and lack of support gained through
participation in group activities (Field et al., 2013) are partial reflec-
tions of social support and also are related to the occurrence of prenatal
stress and anxiety symptoms. Moreover, some researchers have ex-
plored the relationship between prenatal maternal stress and social
support through path model and found that as part of social support,
the family domain plays the most important role in reducing maternal
stress through social support (Shishehgar et al., 2016). The finding
shows that support from family members may be the main source of
social support for pregnant women. This suggests that we can help in-
crease the level of family and social support for pregnant women by
intervening in family members, thereby reducing the occurrence of
prenatal mental disorders.
Therefore, we suggest that comprehensive screening for mental
disorders should be carried out in early pregnancy, and that health-care
professionals should respond proactively to mental health problems of
pregnant women, which is of great significance to avoid adverse ma-
ternal and neonatal outcomes in high-risk groups. Moreover, the social
support and the family care have a greater impact on the mental health
of pregnant women, the medical authorities should focus on inter-
vening in family members of pregnant women, such as requiring family
members to participate in prenatal health education with pregnant
women, providing different types of health education programs for
different family members and setting up consulting platforms of peri-
natal nursing for families. Certainly, we should also strengthen the
health education of pregnancy-related knowledge to the whole society
as much as possible, and provide women with a more friendly social
environment.
According to the purpose of this study, we only analyzed influencing
factors of stress, anxiety, and depression without considering their as-
sociation. Some studies have reported that stress, anxiety, and depres-
sion are co-existed, thus we will analyze and discuss this issue in future
research.
4.3. Limitations
Our study has several limitations: Firstly, all participants were re-
cruited from one region of China, and none of them have a history of
cesarean section due to the exclusion criteria set in the cohort study;
thus, our results may not be applicable to all pregnant women in
mainland China. Secondly, only cross-sectional data from early preg-
nancy in the cohort study are used, so that the causality could not be
identified and longitudinal studies are needed to be conducted in the
future. Thirdly, despite the extensive application of the 16PF on mea-
suring personality characteristics in the general population, its’ relia-
bility and validity have not been verified in Chinese pregnant women.
Moreover, only the items of one factor (Q2) in the 16PF were used in
this study which may resulted in a poor internal reliability (Cronbach's
X. Tang, et al.
α 0.21). Therefore, an independent scale, with good reliability and
validity, which reflects the self-sufficient personality traits of women is
needed to be developed for future research.
5. Implications
Our study indicates that symptoms of mental disorders character-
ized by prenatal stress are prevalent in early pregnancy among Chinese
women in Chongqing. The influencing factors associated with prenatal
stress, anxiety and depression in early pregnancy are work status, ex-
ercise during pregnancy, smoking, parity, personality traits, presence of
other mental disorders and support from the family and the society.
Therefore, the medical authorities should attach importance to the
screening of prenatal mental health problems of pregnant women and
advocate more care for them from the family and the society.
Declarations of interest
None
Funding
Our study was funded by the National Natural Science Foundation
of China (71,573,027).
Acknowledgments
The authors acknowledge the support of the Yubei Maternity and
Child Healthcare Hospital, the Jiangjin Maternity and Child Healthcare
Hospital, the Yunyang County Maternity and Child Healthcare Hospital,
the Dianjiang People's Hospital and participants as well as the hard
works of team members in the study. The authors also acknowledge the
advice of Professor Xiaoli Yang on psychological scales and the help
from Runmiao Xiong about the language.
Author Contributions
All authors contributed to this manuscript. Xiaoni Zhong conceived
and designed the cohort study and guided research implementation;
Xian Tang administered the project; Dihui Hu, Xian Tang and Zhuo Lu
performed the experiments, supervised the execution of the study, and
checked the quality of data; Xian Tang and Zhuo Lu analyzed the data;
Xian Tang wrote the paper.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jad.2019.05.003.
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